Pediatric formula has come a long way over the years. From homemade mixtures to powders that contain things like human milk oligosaccharides, probiotics, prebiotics and more. Choosing which formula you should start your infant on can be difficult and understanding tolerance and when to try a new formula can be even trickier.
At birth, an infant's gut is underdeveloped and has a lot of 'growing' to do, just like you little one! Most general infant formulas have a lot of casein protein comparatively to what can be tolerated in early weeks of life, increasing the risk of intolerance over that time due to digestibility. Over the first several weeks of life, the infant gut not only matures enough to tolerate higher casein protein intake, but the gut microbiome is starting to become more diverse.
Another reason for frequent spit up in infants is related to volume of feeds - compared to day one of life, an infant's stomach can hold up to 20x as much volume by the end of their first month of life. Therefore, advancing volume too quickly often tends towards more spit up, fussiness and general discomfort. And while too much volume itself can be a culprit of intolerance, an infant's lower esophageal sphincter (the muscle between the esophagus and stomach that prevents regurgitation) has poor strength and needs time to develop as well - tending all infants to have a high risk of spit up when they are younger. Because of these early life obstacles, most infants will have increased tolerance week over week.
While there are a lot factors to tolerance that we noted and many others we didn't (proper positioning, latching, suck, swallow, etc.), we know that there are times that we have checked all of these things off the list and baby is still having issues with weight gain, skin problems, etc., which is when the formula swaps should be initiated.
Most infants will start on a general cow's milk formula - some may have probiotics, prebiotics, have HMOs or not. Each brand will have a few differences in ingredients but for the most part they are very similar and interchangeable. There are also goat's milk and soy protein formulas that have no other major differences compared to cow's milk protein formulas that some mom's or infants may prefer. If your pediatrician or dietitian believe that your infant may have a cow's milk allergy, these products are likely not a good choice given that allergies are secondary to reactions to proteins and these proteins all look similar within the body and the likelihood of your infant truly tolerating goat or soy proteins is low and it is a stop in the road that can be frustrating for everyone involved. Another cow's milk formula you may find would be a lactose free or low lactose containing, another unneeded stop in the road for most infants given that a true lactase deficiency in infancy is rare.
So, where to next? Well, proteins are large molecules made out of smaller molecules called ploy-peptides that are made of di-peptides that are made of peptides that are made of amino acids. Therefore, if we are not tolerating a normal (intact) protein, we must seek out a formula that is starting to break these down for baby before consumption. Partially hydrolyzed formulas would be the next step, followed by fully hydrolyzed formulas. These types of formulas can be good for intolerances and mild food allergies but will still contain some proteins. If your baby is still struggling on fully hydrolyzed formulas, an amino acid formula would be the most broken down and easily tolerated formula there is.
(While this is a brief overview of infant formulas, it is important to note there are a vast variety of formulas that contain different types of fats, high calories, special proteins, etc. and working with a dietitian during formula and weight gain struggles can be very beneficial!)
If your baby is taking in a hydrolyzed or amino acid-based formula, it is worth noting that over 2/3 of children will grow out of a milk protein allergy/intolerance. Reintroduction of milk containing foods at the 9-12mo mark is recommended. The best way to do this is by using the Milk Ladder - a plan that reintroduces milk in a baked form and works up towards drinking milk itself. Reintroduction of milk product with a baked cookie is a typical starting point, then moving onto a muffin, a pancake, then cheese intake followed by yogurt and finally full-on milk. This reintroduction should be done over the course of several weeks and skin and gastrointestinal symptoms should be monitored. It is also important that no other new foods are introduced during this time as to not skew perceived tolerance of milk intake.
If your child is part of the 20%+ that will not grow out of a milk protein allergy, it is important to consider your next best options. Trialing soy milk at 9-12 months would be worthwhile as soy milk is able to provide protein content similar to milk. Pea protein milk products are another great choice for good protein intake. But assuring that the milk of choice is not sweetened is important no matter which milk product you choose as added sugars can lead to excess weight gain, altering of the gut microbiome and increased risk of chronic disease later in life and are not recommended before the age of 2!
Looking for help with formula changes, feeding tolerance, weight gain or food allergies? Give us a call and let us help you and your baby stay nourished!
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